RPT VOLUNTEER EMERGENCY/MEDICAL INFORMATION FORM

RPT VOLUNTEER EMERGENCY/MEDICAL INFORMATION FORM
1. PARTICIPANT/VOLUNTEER NAME (YOUR NAME): _______________________________
2. EMERGENCY CONTACT INFORMATION
Emergency Contact Name and Relationship to Volunteer : ______________________________
Emergency Contact Number #1: ______________________________
Emergency Contact Name and Relationship to Volunteer: ______________________________
Emergency Contact Number #2: ______________________________
3. MEDICAL CONDITION DISCLOSURE
a) Do you have any medical conditions (i.e. important medication, recent injury or surgery,
allergies) that may affect you in the field? ______
b) If yes, please explain:
___________________________________________________________________________
___________________________________________________________________________
4. HEALTH INSURANCE INFORMATION
a) Health Insurance Provider (or none):
_____________________________________________________
b) Group or Policy Number: _____________________________________________________
_______________________________________________________________________________
STATEMENT OF IMPLIED CONSENT (please read):
In the event of an accident, injury, or other life-threatening emergency medical situation,
Reserva Playa Tortuga and its staff will take whatever steps necessary to evacuate the injured
person from the field. By signing the Reserva Playa Tortuga Waiver at the beginning of each field
survey, consent is implied.
Volunteer's Signature: _____________________________________________________
Date: _________
Witness Signature: _____________________________________________________
Date: _________